Internal Medicine Residency News - August 18, 2014

By residency1

From the Director

DUKE.RESEARCH.NIGHT.03 (1)Only a few Seersucker Tuesday's left…make sure to wear the stripes while you can (for you Northerners, no seersucker after Labor Day!). We have a busy week of events, including the Kerby Society Durham Bulls Game, and the JAR/SAR liver rounds with the chiefs!  Mock interviews are in full swing (thanks Heather!) as well.  Rumor has it that the HOLIDAY SCHEDULE is almost finalized so be on the lookout for that as well. Kudos this week to Ryan Huey, Brian Kincaid, Kedar Kirtane and Nina Beri for their SAR talks – excellent job! Also to medical student Mark Draelos from former Duke med student and now anesthesia resident Teresa Crowgey for excellent work on his clerkship, to Kahli Zietlow from medical student Lauren Sayres for being a great intern and teaching on VA Gen Med and to Angela Lowenstern from Cards fellow and future chief Jenn Rymer for managing a very sick CCU as the teaching resident.  Also to 9100 interns Logan Eberly, Stephanie Li, Bill McManigle and Jenny Van Kirk – I got to see first hand their excellent care of some very sick patients as the Transplant ID consultant this week with awesome ID fellow and former Duke resident Meredith Clement. I hope many of you took advantage of the opportunity to order MKSAP's…one per three years is paid for by the program.  There are also MKSAP books to borrow from Jen's office as well, donated last year by Cardiology Fellowship Director Andrew Wang. We are excited about all the opportunities for QI events this year.  Having Dr. Daisy Smith give Grand Rounds on High Value Care was outstanding, and Lish Clark and the QI team will be bringing many future opportunities to the group.  The GME incentive program is in full swing, so look for updates on this exciting program as well. This week's Pubmed from the Program goes to Amanda Elliott.  Dastani Z, Hivert MF, Timpson N, Perry JR, Yuan X, Scott RA, …, Elliott AL, …, Munroe PB, Kooner JS, Tall AR, Hegele RA, Kastelein JJ, Schadt EE, Strachan DP, Reilly MP, Samani NJ, Schunkert H, Cupples LA, Sandhu MS, Ridker PM, Rader DJ, Kathiresan S.. Novel loci for adiponectin levels and their influence on type 2 diabetes and metabolic traits: a multi-ethnic meta-analysis of 45,891 individuals. PLoS Genet.. 2012 Mar; 8(3): e1002607. Planning on studying for boards?  I found this while I was doing some research for our curriculum "Back to Basics" project…the NEJM Knowledge+ package …https://secureknowledgeplus.nejm.org/ It is an interactive board review package with study strategies, questions, etc.  Looks quite good.  Pricey ($310) for residents and fellows, but some people may consider this for their ongoing study and review.  If you decide to try it, let us know what you think.  We will also be talking about it in our GME meetings as perhaps an adjunct to MKSAP Mondays…gives us a new question bank to try out and some new formats. Have a great week! Aimee [divider] [box]

What Did I Read This Week?

submitted by: Nilesh Patel, MD

[caption id="attachment_16018" align="aligncenter" width="124"]Nilesh Patel, MD, MS Nilesh Patel, MD, MS[/caption] [box] This week, two cases on sign outs revolved around questions of pulmonary hypertension in general. Though the cases were not, in one case, pulmonary arterial hypertension and, in the other, a case with a single clear cause, the timing of the cases this month do coincide with new guidelines in Chest (Chest. 2014;146(2):449-475) about pharmacologic management of pulmonary hypertension. For our interns, pulmonary hypertension is divided into five groups: pulmonary arterial hypertension (PAH, group 1), pulmonary hypertension due to left-sided heart disease (group 2), pulmonary hypertension due to lung diseases and/or hypoxia (group 3), pulmonary hypertension due to chronic thromboembolic pulmonary hypertension (CTEPH, group 4), or pulmonary hypertension due to unclear multifactorial mechanisms (group 5). These guidelines are specific to patients with pulmonary arterial hypertension (PAH), and cannot be applied to the other groups of pulmonary hypertension. One important point to remember is that no approved therapy for PAH has been shown to prevent progression of the underlying pulmonary vascular disease. PAH remains an incurable disease; the goal of treatment is to reduce symptoms, improve function, improve hemodynamics, and potentially slow progression of disease. The first category of patient is the asymptomatic patient with pulmonary hypertension, who in truth is rarely identified. If stable, asymptomatic disease, no treatment is recommended (though there is no consensus recommendation on how to define stability). For patients with symptomatic pulmonary hypertension, the guidelines recommend vasoreactivity testing (a challenge of inhaled nitric oxide or IV acetycholine, epoprostanol, or adenosine to determine if the pulmonary arterial pressure lowers as a result). First line treatment for patients who demonstrate acute vasoreactivity and have no contraindications (hypotension, right heart failure) is an oral calcium channel blockers (CCB). Symptomatic patients are divided into WHO class II (slight limitation, comfortable at rest), class III (marked limitation, comfortable at rest), and class IV (inability to carry out any activity without symptoms). For class II patients who failed CCBs, approved therapies include: -       Endothelin receptor antagonists (bosentan, ambrisentan), which improve 6 minute walk times and in some cases are thought to improve cardiopulmonary hemodynamics and delay time to clinical worsening. -       PDE-5 inhibitors (sildenafil, tadalafil), which improve 6 minute walk times. -       Or Riociguat, which was pulished about last month in the NEJM. It is a member of a new class of compounds  (soluble guanylate cyclase stimulators), may improve 6 minute walk times, may improve hemodymanics, and, interestingly, may be of benefit not only in PAH but in chronic thromboembolic pulmonary hypertension (CTEPH, group 4 PH). (NEJM 2013;369(4):319-29). For class III and IV disease the above medications are indicated. However, for worsening/progressive WHO Class III disease, an inhaled (iloprost) or IV (epoprostenol, treprostinil) prostacyclin should be initated. For those with class IV disease, and intravenous prostenacyclin should be used. These drugs are not indicated in WHO Class II disease because of their side effects, complications of continuous infusions, and overall cost. [divider]

Clinic Corner

PRIME Clinic Corner

Hi PRIME team: Thanks to everyone for working with staff to make this year’s transition go smoother.  Just remember to ask your team’s interns if they need any assistance with juggling clinic and other responsibilities.  The ACS messages can be confusing if it is not a straight forward refill. If you have not met with your team and your team attending to work out coverage for the year  and review expectations please send out an email and get a meeting scheduled. Joshua Briscoe is working on a ROS sheet to hand out to patients when they check-in, please let either of us know if you are interested in helping or providing feedback.  The COMP narcotic spreadsheet should be assisting all of you in managing your patients with chronic pain. Please let me know if you have any suggestions. We are working on starting  health and wellness group class in the near future for our Prime patients and  a pain psychology class for our patients with chronic pain in a few months.  Will keep you posted on the details. We are all excited about another year together.  Please stop and say Hi to our now COMPLETE family.  We have many new faces that have started working in the last few weeks. Have a great week! Sonal [divider]

QI Corner

Great to hear all of your ideas at last week's PSQC meeting. Stay tuned for a home-grown "Choosing Wisely" campaign to improve the value of care that we Duke residents provide. As always, get in touch with me if you want to join the team in making this happen. Here is an update on SRS reporting, one of the measures for this year's GME incentive program. To get the $200, there needs to be a total of 1972 SRS reports from residents during this academic year. See below. Residents submitted a total of 23 in July, which is on pace to be WAY more than in 2013-2014, but still not enough to get us on track for the $200 goal. But you can change that! SRS reports don't take long, and they have impact. Let's get in the habit of doing a LOT of them.  
Jul-14
SRS Total 1447
SRS by Trainees 23
% by Trainees 2%
Total Submitted by Trainees (YTD) 23
Total Trainees 986
Average # of SRS per trainee 0.0233
Goal (2.0/trainee) 1972
Total Remaining Needed 1949

From the Chief Residents

Grand Rounds

Friday, August 22 - Dr. Christopher Granger, Cardiology (Novel Anticoagulants)

Noon Conference

Date Topic Lecturer Time Vendor
8/18/14 SAR Emergency Series: Pearls from Dr. G Dr. Galanos 12:15 Subway
8/19/14 MED-PEDS Combined Tim Mercer 12:15 Dominos
8/20/14 Resident M&M QI Team 12:15 Cosmic Cantina
8/21/14 QI Patient Safety Noon Conference 12:15 Rudino's
8/22/14 Chair's Conference  Chiefs 12:00 Chick Fil A
 [divider] 

From the Residency Office

Stead Resident Research Grants- Request for Proposals

For All Internal Medicine, Med-Peds, and Med-Psych Residents We are pleased to announce the Request for Proposals for the inaugural “Stead Resident Research Grant” applications. We are grateful to the leadership of the Stead Scholarship Society for their generosity to support resident research and our Stead Leaders for their mentorship and for promoting your scholarly activities ! The applications due on September 1, 2014 for a funding start date on October 1, 2014. Please find attached the Stead Resident Research Grant Instructions-2014, Stead Resident Research Grant Application Forms-2014, Human Subjects example,  and NIHSAMPLE Biosketch Form.   Please include your mentor’s NIH Biosketch and support letter with your application. Please see  link below for Biostatistical Support resources available to you for your projects and discuss with your mentor. http://residency.medicine.duke.edu/duke-program/resident-research/biostatistics-and-data-management-support Each proposal must have a Human subjects section that describes the protections of the patients and patient data, describe the consent procedure if applicable, status of IRB protocol (to be submitted, already submitted or already approved, as appropriate) etc. This section is required whether to not your project is a retrospective or prospective study, whether patient identifiers are exposed (or not) during data collection/analysis, whether consent is to be obtained or there is a waiver for consent. Please see attached example language that you can adapt to your own protocol after discussing with your research mentor who has already thought about the Human subjects issues. Wishing you continued success with your research projects ! Murat Arcasoy and Aimee Zaas  

Flu Vaccination Season 2014

As you know, Duke University Health System (DUHS) requires all healthcare workers who perform their duties in a DUHS facility or a community home-based setting to be vaccinated annually against the flu. This is in alignment with our core value of “caring for our patients, their loved ones and each other.” Annual vaccination against influenza, or policy compliance through a granted medical or religious exemption, is a condition of employment for all DUHS employees. Annual vaccination or policy compliance is also a condition of access to Duke Medicine facilities for those holding clinical privileges in a Duke Medicine facility and learners who wish to train in our facilities. With this in mind, please note these key dates for this flu vaccination season:
  • Start of Flu Vaccination Season: Thursday, September 18, 2014
  • Applications for Medical or Religious Exemption should be submitted before Friday, October 17, 2014.  This will allow sufficient time for review and for communication of the review decision. Please note: Due to the availability of an egg-free formulation of the flu vaccine, egg allergy will no longer be a valid reason for a medical exemption.
  • Policy compliance through vaccination or granted exemption by Monday, November 17, 2014
We will kick off our annual flu vaccination campaign with a 24-hour Duke Medicine Mass Flu Vaccination drill. The drill will begin on Thursday, September 18, 2014. Mass vaccination clinics will be available at each of the hospitals with peer vaccination available throughout DUHS. Following the drill, we will begin our annual flu vaccination program, during which time we will provide many additional opportunities for you to get vaccinated. A schedule of vaccination clinics is posted on the employee intranet at https://intranet.dm.duke.edu/influenza/Lists/Calendar/calendar.aspx.  This list will be updated throughout the flu season. Vaccination is also available at Employee Occupational Health and Wellness (EOHW) during business hours. If you have questions about the flu vaccine or its availability, please visit the DUHS Influenza Resource Guide or duke.edu/flu, ask your manager or contact EOHW. Together, we can stop the flu. Thank you for your commitment to keeping our patients, and our community, safe and healthy.

New System for Requesting Interpreters

As a reminder, Duke University Health System is implementing a new web-based system to request the services of a medical interpreter. Beginning on Aug. 18, 2014, Duke University Hospital, PDC and hospital-based clinics that are currently being serviced by interpreters from International Patient Services (919-681-3007) will be able to use a website to request an interpreter via an icon on PIN and non-PIN workstations. The system, called ServiceHub (https://q.servicehub.com/sso/duhs/r2 ), will simplify and streamline requests for language assistance and will enable users to track the process, including making medical interpreter requests and monitoring the status of requests to know when interpreters arrive on-site and complete the assignment. This system will also enhance the ability to monitor how interpreters are deployed, enabling users to better estimate response times and International Patient Services to provide additional support to areas in high demand for interpreter services. ServiceHub is intended to replace the language assistance request calls that are made to 919-681-3007. While the system is designed to be user-friendly, training materials are available through the Learning Management System (LMS), accessed by logging onto Duke@Work or via the following URL: https://vmw-lmsweb.duhs.duke.edu/SabaLogin After logging in, search the LMS for “ServiceHub Interpreter Request System - Requester Training.” Hospitals that use ServiceHub to dispatch interpreters report dramatic improvement in response times and improved efficiency by an average of 30 percent. Please share this information with any members of your staff who may request interpreters. The International Patient Services team will be ready to assist and support you while we transition to this new dispatching system. For questions regarding the new ServiceHub interpreter request system, please contact: International Patient Services 919-681-3007 or 919-668-2431 Nouria Belmouloud Pager: 919-970-0387  

New Jackets/Fleeces for 2014!

Today, AUGUST 18, is THE LAST DAY TO ORDER AND PAY FOR YOUR JACKET!  Please contact Lynsey Michnowicz in the MedRes office if you have any questions! https://duke.qualtrics.com/SE/?SID=SV_eV6magzZYP906CV Jacket will be Black with the Duke Medicine logo. photo

Stead Society Trivia Night

The Warren Society would like to invite house staff and Stead preceptors from all the Stead groups to Stead Trivia Night, held starting at 7:30PM (dinner at 7:30, trivia at 9) on Wednesday, August 27, at Bull McCabes (427 West Main St., Durham).  If you come, we will feed you dinner and provide you with tasty beverages of your choice.  The trivia is really just an excuse to gather the residency class, so there is no need to be a trivia buff to participate.  Please come and chat with your resident colleagues in a relaxed atmosphere.  Also, please feel free to bring your families and significant others. Sincerely, Steven Crowley on behalf of the Warren Society

Information/Opportunities

Hospitalists Practice Opportunity in PA 7-2014 Announcement Geriatrician Opportunity Elkin Hospitalist Montana Hospitalist Summit Placement Service Washington State Opportunities Madison WI opportunities www.mercydesmoines.org    

Upcoming Dates and Events

August 19th - Liver Rounds, Tyler's Tap Room August 27th - Drs. Schuyler Jones and Manesh Patel at Alivia's  - Careers in Cardiology August 27th - Stead Society Trivia Night, Bull McCabes (427 West Main St., Durham)  

Useful links

Share